Authorizations

Contact Authorization and Referral Management for information about authorizations procedures including denials and appeals.

1-808-432-5687
Monday – Friday 8 am – 5 pm
Fax: 1-808-432-5691 or 1-808-432-5667

Kaiser Permanente (KP) Pediatric Occupational Therapy Services are based upon medical necessity with an emphasis on functional outcomes. The focus of KP Pediatric Occupational Therapy Services is to increase a child’s successful participation and independence with their self-care, productive and leisure activities. In alignment with this focus, Kaiser will only authorize claims payment for Pediatric Occupational Therapy Services with the following CPT codes, claims for services not included on the list below will be denied.

Evaluation
97165: OT Evaluation, Low Complexity
97166: OT Evaluation, Moderate Complexity
97167: OT Evaluation, High Complexity
97168: OT Re-evaluation

Therapeutic Procedures
92526: Treatment of swallowing dysfunction/oral function for feeding
97110: Therapeutic Procedure using Exercise
97112: Neuromuscular Reeducation
97129: Therapeutic Interventions that focus on Cognitive Function + 97130 (for each additional 15 minutes of 97129)
97530: Therapeutic Activities
97535: Self-care/Home Management Training

Note: this excludes specialty PT services, such as aqua-therapy, pelvic floor, lymphedema, pediatric cases.
 

Authorize number of visits for PT services for chronic/nonacute conditions

• Six (6) initial visits: one (1) evaluation visit and five (5) treatment visits, maximum of four (4) units = one (1) hour per visit.

Authorized number of visits for PT services for acute conditions (new post-operative, fracture, new stroke, acute exacerbation of existing condition due to an event)

• Twelve (12) initial visits: one (1) evaluation visit and eleven (11) treatment visits, maximum of four (4) units = one (1) hour per visit.

For initiation evaluation

• The member’s condition is acute, subacute, neurodevelopmental, an acute exacerbation of a chronic condition or a function-limiting chronic condition.
• The member’s condition can be expected to show measurable, significant, sustainable functional improvement within a reasonable and generally predictable period of time as a result of the prescribed PT.
  

For initiation of PT treatment

• A therapy plan of care (POC) that includes the member’s diagnosis with planned treatment interventions; frequency and duration; measurable, time-specific, functional goals for therapy; and expected potential for achievement of goals and includes patient/caregiver education and training.
• You are required to number the visits/progress notes for each treatment session/visit (i.e., Visit 1, Visit 2, etc.).
  

Request for extension of the number of visits – documentation requirements

1. Visit/progress notes that address each treatment goal, with inclusion of member’s initial status, last reporting period status and current reporting period status, with specific reference to the parameters outlined in previous status. Objective measure parameters must be consistent across reporting periods. You are required to number the visits for each treatment session/visit (i.e., Visit 1, Visit 2, etc.).
2. The planned treatment techniques and interventions that are detailed including amount frequency and duration required to achieve ongoing progress toward functional, measurable goals.
3. Identification of any health conditions or other factors which could impede the member's ability to benefit from treatment.
4. A summary of the member’s response to therapy, with documentation of any issues which have limited progress.
5. A brief prognosis statement with clearly established discharge criteria
6. An explanation of any significant changes to the member’s POC, and the clinical rationale for revising the treatment plan.
7. Completion of the Kaiser Short-Term Rehabilitation Therapy Extension form.
   

Discontinuation of PT services

• Member no longer demonstrates functional impairment or has achieved goals set forth in the POC or has returned to their prior level of function.
• Member has adapted to impairment with assistive/adaptive equipment or devices.
• Member has been receiving services over an extended period of time and it cannot be determined whether the progress is due to therapeutic intervention or natural development.
• Member is unable to participate in the plan of care due to medical, psychological, or social, complications.
• Member (and/or family/caregiver) is noncompliant with Home Exercise Program and/or lacks participation in scheduled therapy appointments.
• Member does not meet continuation criteria.

Oahu, Maui and Hawaii
Referral guidelines and related policies to assist you when managing patients on the islands of Oahu, Maui and Hawaii are available for your reference in Chapter 11 of the Affiliated Practitioner Manual.

Kauai, Lanai and Molokai
Referral guidelines and related policies to assist you when managing patients in the Neighbor Island Network are available for your reference in Chapter 17 of the Affiliated Practitioner Manual.

The utilization management programs and continuity of care benefits and services available to Kaiser Permanente members are described in Chapter 8 of the Affiliated Practitioner Manual.

Kaiser Permanente members are covered for these services based upon their covered group benefits.